14/04/2023

Recruitment/Periodic Examination Form/Report for Heavy and Dangerous Work in Turkey Template

WORKPLACE 
Title  
SSI Registry No.  
Address  
Tel and fax  
E-Mail  
I hereby declare that I agree to be examined at the initial/periodic examination and that the information I have provided during the examination is correct and complete.   Name and Surname of Employee SIGNATURE ——————————————————————————————————————————–   EMPLOYEE 
Name and surname  
T.C.Identity No  
Place and Date of Birth 
Gender 
Education status 
Marital status Child No. 
Home Address 
Tel No./e-mail 
Profession 
His/her job (To be defined in detail) 
Department he/she works in 
Previous places of employment (From today to the past)Line of BusinessPerformed Duty 
1.   
2.   
3.   
History 
Blood group 
Congenital/chronic disease 
Immunisation
  – Tetanus 
  – Hepatitis 
  – Other 
Family history (chronic diseases, immunisation)
MotherFatherSibling 
    
MEDICAL ANAMNESIS
1. Have you experienced any of the following complaints?No 
– Cough with phlegm  
– Shortness of breath  
– Chest pain  
– Palpitations  
– Back pain  
– Diarrhoea or constipation  
– Pain in the joints  
2. Have you ever had any of the following diseases?No 
– Heart disease  
– Diabetes  
– Kidney disease  
– Jaundice  
– Stomach or duodenal ulcer  
– Hearing loss  
– Visual impairment  
– Nervous system disease  
– Skin disease  
– Food poisoning  
3. Have you been hospitalised?No If yes, diagnosis? 
4. Have you had an operation?No If yes, why? 
5. Have you had a work accident?No If yes, what happened? 
6. Have you been subjected to examinations and examinations related to suspected occupational diseases?No If yes, the result? 
7. Have you received a disability?No If yes, what is it and the rate? 
8. Are you currently receiving any treatment?No If yes, what is it? 
9. Are you smoking?No  
 Quitted  Before……….month/yearSmoked………….month/year 
 Yes Since……….yıldır…………..piece/day
10. Do you drink alcohol?No  
 Quitted  Before …………..yearsDrank…………..eyars 
 Yes Since……….year…………..frequency
PHYSICAL EXAMINATION RESULTS
a) Sense organs 
   – Eye 
   – Ear-Nose-Throat 
   – Leather 
b) Cardiovascular system examination 
c) Respiratory system examination 
d) Digestive system examination 
e) Urogenital system examination 
f) Musculoskeletal examination 
g) Neurological examination 
Ğ) Psychiatric examination 
h) Other 
   -TA :                              /                               mm-Hg
   -Nb  :                            /       min.
   -Height:                        Weight:                                           Body Mass Index :
LABOUR FINDINGS
a) Biological analyses 
– Blood 
– Urine 
b) Radiological analyses 
c) Physiological analyses 
– Audiometer 
– SFT 
d) Psychological tests 
e) Other 

OPINION AND CONCLUSION * :

1- …………………………………………………………………………………………………………………………………… is physically and mentally fit for work.

2- ………………………………………………………………………………………………………………….. is suitable to work with the condition.

(*As a result of the examination, it will be stated whether the employee can work in night or shift working conditions and whether the employee is suitable for working with these conditions if there is a suitable tool, equipment, etc. complementing the health and integrity of the body…)

SIGNATURE                                                                                                                                                                                                                                                    

Name and Surname : ………… / …………. / 20………….

Diploma Date and No:

Diploma Registration Date and No:

Workplace Medicine Certificate Date and No: